To care,
And to teach.
Provide
the initial and ongoing care for the diabetic children and their caregivers.
Establishing
standard protocols for management of diabetes for general pediatricians.
Provide
education for the schools.
Provide
care for patients with all endocrine disorders in term of diagnosis and
treatment.
Perform
all dynamic tests necessary for the diagnosis of endocrine diseases.
Establish
standard protocols for the investigations and management of these endocrine
diseases.
Training general
pediatricians for the different aspects of managing pediatric endocrine
disorders.
To provide comprehensive medical care (including emergency and intensive
care) to sick children.
To promote child welfare through active interaction with parents or legal
guardians, schools and other relevant agencies.
To provide general and specialist
Pediatric training to undergraduate students and graduate doctors.
To promote in-service training
and continuous medical education.
Maintaining
normal growth and development of diabetic children.
Preventing
acute complications.
Preventing
long-term complications.
Maintaining
normal every-day activities, specially school.
Give the child/parents enough knowledge and
skills to be confident in managing his day-to-day problems related to diabetes.
Vision: Endocrinology
– 2(Endocrine)
Management
of all above mentioned endocrine disorders and minimizing complications of the
different therapeutic modalities.
Maintaining normal growth (height potential)
of the patients with endocrine disorders.
Educating parents/patients about the nature
of their disorders to be able to achieve the maximum benefit of the therapy and
meet their goals and expectations.
Avoid unnecessary investigation
of patients with short stature by providing appropriate explanations and
education for the patients and their parents, and
by
regular follow-up.
STRUCTURE
Structure: General
Paediatric
I No of Beds:
There are 95 beds (68 general and 27 private) for the
pediatric patients in the hospital, distributed in 3 wards.
II Bed
Allocation
General
Pediatric Wards:
Ward 5,6 each has 33
beds and ward 7 has 29 beds. Each ward has 9 private beds, one of which is an
isolation room. Another room is equipped with central oxygen, air and suction,
so that a ventilator can be fitted and used when needed (e.g. when there is no
available bed in our ICU and elsewhere).
There are 2 general
paediatric units (A and B), Unit A contains ward 6 and half of ward 7, while
Unit B contains ward 5 and half of ward 7, and endocrine and diabetes unit
utilize the general pediatric beds.
Casualty Unit:
It has
3 examination rooms, an observation room with 8 beds, a large room for
ventoline nebuliser, which can accommodate up to 10 patients and a large
waiting area. There is one common resuscitation in the causality area used also
by medical and surgical departments.
Outpatient Clinics:
It
consists of 5 rooms for examination and a nurses’ room.
Structure: General
Paediatric
III Medical
Staff : (Physicians)
Head of the Department: Dr.
Qusay Al-Saleh
Unit A:
Dr. Mohammed Zaki, head of the unit Consultant
Dr.
Esam A.Raheem Consultant
Dr.
Ghalia A.Mutairi Specialist
Dr.
Magdi Shafik Specialist
Dr.Saad
Al-Otaibi S.Registrar
Dr.
M.Taha S.Registrar
Dr.Hanan
Al-Mutairi Registrar
Dr.
A.Abdu Registrar
Dr.
Inas Ramadan Registrar
Dr.
Sameer Ojaila Registrar
Dr.
Kays Jaleel Registrar
Dr.
M.A.Sameer Registrar
Dr.
M.Alsalhi Registrar
Dr.
M.M.Shawkat Registrar
Dr.
Nowayyer Alharbash Registrar
Dr.
Mashael Alkandari A.Registrar
Dr.
Mishal Alkandari A.Registrar
Dr.
Khalid Al-Ohman A.Registrar
Unit
B:
Dr. Hussein Alonaizy, head of the unit Consultant
Dr.
Othman Abou Shanab S.Specialist
Dr.
Hani Nadi Specialist
Dr.
Hameed Alonaizy S.Registrar
Dr.
Yasir Shaalan S.Registrar
Dr.
Anaam Alnakkas S.Registrar
Dr.
Hanan Alqattan S.Registrar
Dr.
Ameer M.Ahmed Registrar
Dr.
Ahmed Ismaeel Registrar
Dr.
Ahmed Al.haj Registrar
Dr.
Osama Abdulfattah Registrar
Dr.
Hamdi AbuAlhasan Registrar
Dr.
Rasha Alsafae Registrar
Dr. Shakir Albahee Registrar
Dr.
Mohd. Altakruri Registrar
Dr.
Hahsim Eiasa Registrar
Dr.
Bothayna Yusif Registrar
Dr.
Hanan Almajid Registrar
Dr.
Suad Sadik Registrar
Dr.
Fawaz Ak-Baghli A.Registrar
IV Medical
Staff (Nurses):
Head Nurse: One head nurse in ward 5.
Assistant Head nurses: 2 nurses, ward 5 does not have one.
Staff nurses: A total of 74 nurses distributed as follows:
25
nurse in ward 5
26
nurse in ward 6 and
24
nurses in ward 7
Structure: Endocrinology – 1
(Diabetic)
·
No limited number bed capacity as part of
General Paediatric.
·
The diabetes unit is part of the pediatric
department of the hospital.
·
The patients are admitted in the pediatric
wards (5 and 7), which are located in the ground floor of
II Medical Staff: (Diabetes team)
The
diabetic team includes the following members:
·
Dr. Majedah Abdul-Rasoul Pediatric
Endocrinology Specialist,
Head of the Unit
·
Dr. Hessa Habib Senior Registrar
·
Dr. Maha Alkholy Registrar
·
Mrs
Salwa Al-Ostath Dietician
·
Mrs Olfat Shawqi
·
Mrs Layla Ali Diabetes
Foot Clinic
·
Mrs Rana Khalid, Zainab Hussein Child life Team
·
Mrs Hanan Al-Adwani Social Worker
Structure: Endocrinology –2(Endocrine)
I Bed Allocation:
The patients are
admitted to the pediatric wards, if they need in-patient care. Otherwise, they
are cared for in the outpatient.
II The Endocrine Team:
·
Consultants Dr.
Majedah Abdul-Rasoul
·
Senior Resistrar Dr. Hessa Habib
·
Registrar Dr.
Maha Al-Kholy
III Medical
Staff (Physicians)
Dr. Majedah Abdul-Rasoul, head of the unit
Dr.
Hessa Habeeb, senior registrar
Dr.
Maha Alkholy. Registrar
IV Medical
Staff (Nurses):
·
Part of General Paediatric staff.
FUNCTION
Function:General
Paediatric
Function of the Department:
I Work Schedule:
Hours
of Duty: work starts at
II Ward Rounds:
Each
unit carries out daily business rounds, organized by the senior registrar. Each patient is reviewed and notes on
complaints, physical findings, diagnosis and investigations ordered and results
received are made in the patient’s chart.
Any difficult cases and requests/results of any specialized tests e.g.
CT Scan, MRI, echocardiography etc. are discussed with the consultants. A
summary is written for each patient discharged from the unit.
Each unit has two consultant rounds weekly, with all the
doctors in the unit in attendance. This gives an opportunity to review the
diagnosis and plan management of new admissions and the on going care of
previously admitted patients. It is also an invaluable teaching experience for
the junior staff.
The
sub-specialty unit ( at the moment only endocrine) is responsible for looking
after their patients in the ward if there are any. They are also consulted on
patients as requested by any of the other units.
III Casuality:
There are two doctors who are assigned to the pediatric
casualty unit in the morning between 7.00a.m.and
The doctor in charge decides which child should be given
emergency treatment or sent home after observation in the observation room. Any
patient needing admission is admitted to the ward for further review by the
second on-call doctor.
Patients who require follow up are given appointment in
the relevant outpatient clinic through the referral system and not directly
from the casualty.
IV Outpatients:
They are run by consultants, senior specialists and
senior registrars, in addition to few selective experienced registrars. Each
unit has one day of general pediatric outpatient clinics per week, in which
there are 4 rooms. The patients are seen strictly by referral, there are 1
sub-specialty clinic per week. The following are the current clinics:
Saturday:
1 genetic clinic
1 senior registrar pulmonary
clinic
Sunday:
1 consultant general pediatric clinic
2 specialist general pediatric clinic
1 senior registrar general pediatric clinic
1 consultant / registrar pediatric endocrinology clinic
Tuesday:
1 consultant neonatal clinic
1 senior registrar neonatal clinic
1 consultant diabetes subspecialty clinic
1 senior registrar diabetes clinic
1 pediatric nutrition clinic
1 senior registrar rhematology subspeciality clinic
Wednesday:
2 consultant general pediatric clinic
1 senior specialist general pediatric clinic
2 specialist general pediatric clinic.
1 senior registrar general pediatric clinic
V Call
Duty:
Call duty starts at
makes rounds with
the other doctors between 6 and
VI Daily work shedule for Unit A:
·
Patients are admitted
to the unit on Saturdays, Mondays, Wednesdays and alternating Fridays.
·
Saturday: Ward rounds, done by the head of the unit and attended
by all unit doctors, as well as family physicians, trainees and medical
students.
·
Sunday: Ward rounds done by the consultant
·
Monday: Ward round done by the specialist. Teaching session for
the KIMS candidates organized by the specialist. There is also the
academic activity of the department at
·
Tuesday: Ward rounds done by the head of the unit. There is also
a teaching session for the trainees organized by their assigned physician. At
·
Wednesday: Outpatient day. 5 physicians run the outpatient. The
rest of the unit doctors have rounds on the ward patients.
VII Daily work Schedule for Unit B:
·
Admission days for
unit B are Sundays, Tuesdays, Thursdays and alternating Fridays.
·
Patients’care
responsibilities are distributed among the assistant registrars and the
registrars of the unit. Cases are seen by the assistants and reviwed with the
registrars. The senior registrars and the specialists review any case when
needed.
·
Saturday: Ward round starts at
·
Sundays: Outpatient day. It is run by
specialist and senior registrars. Sometimes, assistant registrars join the
clinic to get used to run the clinic
when needed.
·
Mondays: Rounds are run by the senior specialist or the specialist. At
·
Tuesdays: A special education session is arranged and conducted for the candicates in the training program of
the Kuwaiti Institute for Medical Specialization. There is also a subspeciality
clinic for Pediatric Rheumatology, which was established with the coordination
with the Rheumatology Unit in the Pediatric Department in
·
Wednesdays: Rounds are conducted by the head of the unit, with the attendance of all
unit physicians. All cases are reviwed and weekend plans are set up clearly for
all the patients.
Function:
Endocrinology – 1 (Diabetic)
·
The unit is a sub-specialty unit so,
patients are seen by referral. Urgent cases are seen without referral.
·
Referrals are made from the polyclinics and
the primary health clinics to the unit. The majority of the patients are from
the residential areas that belong to the hospital, however some are seen from
outside the area because not all the hospitals have pediatric diabetic units.
·
Referrals are also made from the general
pediatric department of the hospital, some are referred from the internal
medicine department for outpatient follow up; those aged 12-18.
II The
Head of the Department is responsible for:
·
The development and implementation of the
operational policy
·
The development of guidelines for the
treatment of diabetes in children in its various forms (appendix).
·
The development of the different formats
used in the outpatient for patients with diabetes (appendix).
·
Continuous review and monitoring of the
quality of care provided for the patients and their families.
·
The orientation and continuous education of
the members of the department.
·
Recommendation to the department council and
other organizations for the needs of the unit; including equipments like
glucometers, staff like dietitian and nurse educator and more rooms for the
outpatient clinics.
III Inpatient Policy:
In-patient Care
is provided for:
·
Dynamic growth hormone testing
·
Investigation and management of patients
with hypoglycemia
Function: Endocrinology – 1 (Diabetic,)
·
Patients with ambiguous genitalia; initially
and in crisis.
·
Dynamic testing for patients with puberty
disorders.
(See
attached protocols for the different tests done in the unit)
IV Outpatient
Policy:
Outpatient Service:
·
Sunday:
Dr. Majedah Abdul-Rasoul
·
Dr. Hessa Habib and Dr Maha Alkholy
·
Dynamic tests are done on Wednesdays in Ward
7.
FUNCTION OF THE DEPARTMENTAL COUNCIL
·
The departmental council chaired by
the chairperson of the department (or his deputy), will have a meeting once
every month.
·
Membership of the council: All consultants, senior
specialists, specialists, one representative of senior registrars, registrars
and an assistant registrars (if issues to be discussed involve them) .The
representative of the registrars and assistant registrars are non voting
members.
·
The council will nominate
their representatives to the various hospital committees, councils and
activities.
·
The council will elect
the concerned committee (person) to run the day to day business e.g. duty rote,
post-graduate and in service training, medical records, medical students,
academic activities, mortality/morbidity etc.
·
All promotions, shortages,
problems, major complaints, proposed plans, change of business structure
concerning the running of the department will be discussed in the council’s
meeting.
·
The council
will review and evaluate on continuing basis the clinical privileges of the
staff, to ensure a high level of professional performance by all persons
authorized to practice in the department. Senior members of the council in
closed meeting will decide on the appropriateness of the professional
performance and ethical conduct of members of the department.
·
The council will decide
on the provision of the appropriate educational setting that will maintain
scientific standards and foster continuous advancement of professional
knowledge and skills.
·
The council
will support the appropriate utilization of hospital recourses, and support all
hospital clinical and non-clinical activities that serve to promote and
maintain accreditation of the hospital locally and internationally.
·
Review of the accumulated
CME/CPD points of staff, and evaluation of the CME/CPD activities of the
department.
·
Neonatal unit & Endocrine
unit are part of this departmental council.
Funtion: General Paediatric
(Cont.)
The Departmental Committees:
·
The Preparation for
Accredidation Dr. Qusay
Al-Saleh
Committee
·
The Departmental Accreditation Dr.
Rema Alsawwan
Coordinators Dr.
Majedah abdul Rasoul
·
The Mortality &Morbidity Dr.
Mohd.Zaki
Committee Dr.
Rima Al-Sawan
·
Infection Control & Dr.
Rema
Antibiotic Committee Dr.
Othman
·
Medical Record Committee Dr.
Hani
·
The Drug Utilization Committee Dr.
Othman
·
Anaesthesia Utilization Review Dr.
Adnan
Committee
·
X-ray Utilization Review Dr.
Ghalia
Committee
·
Laboratory & Blood Dr.
Magdi
Producuts Utilization
Committee
Review of Medical records are done in the monthly meeting organized by Dr. Hani.
Randomly selected charts are reviewed. All aspects of the charts starting from
the casuality notes up to the disharge summary, are reviwed with the doctors to
improve the medical writing of all staff.
Job Description of the staff: as specified by the ministry of public health,
fulfilled at all levels of job heirarchy. (for detailed description, see
attached papers).
ADMISSION POLICY
I Admission
Procedures:
·
Any patient admitted to a Pediatric Ward should have the
name of the “ doctor –in-charge” clearly, mentioned on the admission slip.
·
The “ doctor-in-charge” should not be less than a
consultant, that is each patient should be under the care of a consultant.
·
The consultant-in-charge of any patient is responsible
for the over-all well-being of the patient medically, ethically and legally
until discharged from the hospital.
·
Transfer of patient care between units i.e. consultants,
can only be done after mutual agreement of both consultants. This transfer of
care has to be clearly documented in the patient’s notes.
·
Admission to the Department of Pediatrics come from two
sources;the pediatrics Casuality unit and the pediatrics out-patients clinic.
Patient is admitted under each of the 2 different units in turn.
·
A patient who is admitted under the care of ine unit,will always be
admitted under the care of the same unit except if was discharhed against
medical advice in the first admission.
·
A patient who is discharged
from the hospital will be re-admitted to the same unit if he needs admission
within one week from his discharge.
·
A patient who is discharged against medical advice (AMA) will
be considered a new patient if he needs admission
·
The patient who is under follow up in the outpatient by
one of the units will be admitted to that unit if he needs admission even if he
lost for follow up.
II Admissions from the Emergency Room:
●
The Pediatric team on call should decide on immediate admission or
discharge of such patients from the emergency room after a maximum of 2-4 hours
observation/ emergency treatment.
●
This time limit should be adhered to because, the patient
and his relatives need to know for sure what the next line of management is
within a reasonable time and to reduce the congestion and bed occupancy in the
emergency room.
III Admission from the Paediatrics Out-patient Clinic:
·
Those patients are referred to the outpatient clinic from
different sources e.g. polyclinics, colleagues from other departments and
hospitals. The doctor in charge of the clinic carries out detailed assessment
including history, clinical examination and any relevant investigations.
·
A patient is deemed to require admission is sent to the
ward after contacting the registrar of the admitting unit or the person
responsible for the admission that day.
IV Patient
Assessment on Admission:
On
admission to the ward, the patient is seen by the designated doctor in the unit
who should take a full history and carry out a full examination. He/she should
collect and review all investigations, which were carried out in the
outpatient. The junior doctor should then formulate a plan of management, which
should include diagnostic plan, therapeutic plan and the follow-up plan. The
junior doctor should then present the case to the second on call within 2 hours
who would verify the diagnosis, see the relevant investigations and review the
chronological sequence of the problem, review the management plan formulated by
the junior including patient and family education. The senior registrar would
then present the case to the consultant-in-charge.
V In Hospital Patient Assessment:
Each unit carries out a business round every morning, under
the supervision of the senior registrar. At these rounds, the registrar of the
unit presents the cases and the new problems to the senior registrar who would
take the final responsibility in taking the appropriate decision for each
problem. The latter would brief consultant-in-charge about the new problems and
the management plans.
The daily inpatient
assessment is carried out according to the problem oriented plan, that is SOAP
as follows:
·
S “Subjective”: The junior doctor records the patient’s new complaint at
the time of the clinical interaction with the patient
·
“Objective’’: The junior doctor records his observations “clinical
examination and results of any new investigations.
·
A “Assessment”: After listening to the patient, carrying out the
clinical examination and reviewing the relevant lab results. The junior doctor
should record his/her assessment of the present condition of the patient e.g.
chest infection, dehydration, anemia etc.
·
P “Plan’’: The junior
doctor should then indicate what are his/her plans to verify the condition
suspected under assessment above. This plan should be:
-
Diagnosis: Investigations to prove or disprove the suspected
condition.
-
Therapeutic: Treatment provided to treat the condition and help the
patient
The SOAP method of
follow up has many benefits:
·
It encourages the junior doctor to take full history and carry out full
clinical examination to reach an assessment and management plan.
·
It enforces better patient care.
·
With time the junior doctor will see for him/herself the improvement in
his/her assessment and management plans.
·
This method gives objective evidence to the senior about the improvement
or otherwise in the clinical management of the junior staff.
·
The Consultant Ward Round follows after the completion of
the business daily work of the unit. The patient is presented to the consultant
by the junior doctor and a comprehensive review of the patient’s care up to
date is carried out and the future plan is outlined. Discussion is held, as
necessary with the patient’s parent(s)
or other legal guardian.
VI Consultation from other units and second opinion referrals:
·
These consultations are done verbally by phone ,fax or written. The time
and date of such consultation is to be clearly documented in the patient’s
notes.
·
All referrals for a second opinion either to a sub-specialty unit in the
department or to other consultant outside the department should always be in
writing.
·
All opinions or management plans suggested by the consulted person are
only suggestions and it is the responsibility of the consultant in-charge of
the patient to discuss the suggested plan, accept it, modify or even reject it.
·
It is always preferable to reach a consensus by personal contact and
discussion of each consultation.
VII Discharge Plan:
Once the patient has recovered
from his/her acute illness and is fit for discharge the following points are
observed:
·
The patient’s condition is carefully explained to the
parents and the patient (where appropriate).
·
In patients with chronic or genetic illnesses, proper
counseling is done with the family as appropriate, making sure that there is as
much understanding of the condition as possible.
·
The future plan for the patient’s care is explained
carefully to the parents and/or guardian.
·
Detailed information should be provided to the parents of patients
referred to other hospitals about their immediate needs and when and how to get
where they have been referred.
·
All discharged patients should be provided with a “ discharge summary”
form, which should be filled in full. This form is essential as the patient can
use it on seeing his/her primary care physician and in coming back to the
hospital in case of emergency.
·
When appropriate,and if available, an educational written leaflet about
the child's illness is given to the parents to increase the level of warenwss
of the illness.
VIII Follow up Plan:
Patients are given follow-up appointment in the outpatient
clinic based on their final diagnosis and their need.
Admission
Policy: Endocrinology
I In-Patient Policy Of The Unit:
·
All patients are admitted to the hospital at
diagnosis for about 4-7 days.
·
The nature of the immediate management
depends on the patient’s condition.
·
Patients with ketoacidosis are started on
intravenous therapy, while patients with hyperglycemia can be started on
sub-cutaneous insulin.
·
Parents are given the support to overcome
the initial grieve following the diagnosis
·
Education program is usually started after
the acute phase of the disease is managed.
·
Educational/Teaching Program for newly
diagnosed patients with diabetes (see accompanied appendix):
1
The program is
done over 5 days, and stared with at least one member of the family plus the
child, or 2 members if the child is less than 6 years of age.
2
The speed of education
depends on the parents and the child.
3
Families are given choices
about the different glucometers available in the markets, for them to decide
which one to get.
4
They are then taught on the
machine they get to avoid confusion.
II Discharge
Plan:
·
Patients are provided with a contact number
of one of the team members for emotional support and day-to-day problem
management
·
Parents are given written instruction to be
delivered to their school, with instructions on how to handle acute emergencies
like hypoglycemia.
III Follow up Plan:
·
All newly diagnosed patients are seen
weekly, for further education and insulin dose adjustment. The weekly follow up
is done in the meeting room of ward 5.
·
Patients are then seen twice a month until
the education plan is in forced completely, after which they are seen every 2
months in the outpatient.
IV Out-Patient Policy:
The
outpatient is organized as follows:
Sunday: Dr. Majedah, Dr. Maha (Room
2)
Dr. Hessa (Room 6)
Tuesday:
Dr.
Majedah , Dr. Maha (Room 2)
Dr. Hessa (Room 1)
Mrs Salwa: Dietician (Room 5)
Wednesday:
Dr.
Majedah,
V On-Call
Schedule:
Dr.
Majedah and Dr. Hessa are consulted on every diabetic patient admitted to the
hospital.
Patients themselves can
contact the treating physician from the unit any time of the day (24hrs).
General Paediatric
EVALUATION OF THE DEPARTMENTAL POLICY
Strengths:
Accessibility of services
Clinical review
Infection control program
Effective decision making
Diagnostic skills
Availability of observation
area services
Involvement of the service in
undergraduate and post-graduate teaching (e.g. Kuwaiti Board for Paediatrics,
Family Medicine Board)
Internet facilities
Computers and printers in
each doctors' room
Weaknesses:
Inadequate computerized
information system and insufficient training in the use of information
technology
Overcrowding of casualty
Difficulty in implementing
decisions
Lack of Paediatric ICU
Opportunities:
Recruitment of newly
appointed high quality staff (e.g. senior registrars)
Involvement in new clinical
specialists
Threats:
Undetermined future of the
service or the staff
Lack of incentives for staff
Lack of adequate space for
staff meetings/recreation room
Reduction in learning
opportunities, lack of books
CONTINUOUS PROFESSIONAL
DEVELOPMENT (CPD) and CONTINUOUS MEDICAL EDUCATION (CME)
The department receives new medical graduates
(trainees), registrars and medical students. One of the missions of the
department is to teach and all senior staff in the department has an obligation
to train and teach junior doctors and medical students.
I The
Annual CPD/CME’s of the Department:
The academic activities of the
department are categogorized as category 2. Every 6 months the department
issues certificates for each doctor, with the total points he/she has earned
for that period. The activities includes, the morning meeting, clinical meeting
twice/week, the chart review meetings, mortality meetings every 3 months and
radiology meeting monthly. Each has 0.5 point of category 2.
II The
Evaluation of the Efficacy of the CPD:
Special form for the evaluation of
the CPD programms (lectures) are used and the evaluation is discussed with the
candidate. Forms for valuation for the tutorials are being developed. The
mortalities are reviewed in the mortality meeting, and recommendations are set
after each meeting.
III Undergraduate
and Postgraduate Training:
III-A Graduate
Training:
A-1 The entire
junior doctors in the department –registrars, assistant registrars and
trainees) are considered to be in a training program.
A-2 Trainees
i.e. these are fresh medical graduates who rotate through the department for 8
weeks during which they are attached to one of the service units.
A-3 An essential
part of the clinical teaching of the junior staff is to get them to take good
medical history and perform a thorough medical examination with the aim of
reaching the right diagnosis. Eventually they are also expected to be able to
formulate rational management strategies.
A-4 The junior
doctors, through their daily activities, on-call hours and other patient
contacts, are in full interaction with more senior staff (senior registrars and
consultants). These encounters are geared towards the basic principles of
pediatric training. Through direct supervision and continuous instructions, the
clinical skills of the junior mature within 3-4 years of joining the
department. By the end of their training, these doctors are eligible for
examinations of different certifying bodies e.g. the Kuwait Medical Board,
Royal College etc.
A-5 Ethical and
moral issues are given prominent importance. These ideals are emphasized on a
daily basis to all junior staff in the department. Our aim is to produce good
clinicians with excellent moral and ethical values.
A-6 All through
their training staff are taught skills of communication with patients, their
relatives and guardians. This is even
more important in patients with inherited illnesses or genetic disorders.
III-B KIMS
Program:
The department of Pediatrics
runs a structured postgraduate program under the auspices of Kuwait Institute
for Medical Specialization, leading to the Fellowship of the Kuwait Medical
Board. This is a four-year program and the candidate rotates through the
various units and subspecialty postings in Farwania hospital and other
hospitals in
III-C Medical
Students Training:
C-1 The
department receives three batches of 6th year medical students every year for a
three-month rotation. On joining the department, they are given a detailed
schedule of activities. Apart from Farwania hospital, the following hospitals
are also used for their training- Amiri, Adan, Mubarak and the Maternity in
C-2 Structured
didactic lectures are given in the first four weeks of the posting between 2
and
C-3 Because of
their relative clinical inexperience, they are allocated patients on a daily
basis, whom they clerk and examine. Each morning a tutorial is held with a
consultant in the department at which the students present their cases at the
bedside.
C-4 In the last
3 weeks of the posting the students are given more responsibility to act as
junior trainees. They are attached to one of the service units and are expected
to be fully integrated into the activities of that unit.
C-5 In addition
the student are expected to take calls on 1.4 basis during which they attend
evening business rounds with the senior registrar. They also see new patients,
along with the registrar on-call, as they come in.
C-6 The students
get signed up for every tutorial they attend and if they miss more than 20% of
the sessions they may not be allowed to sit the final examination.
III-D Academic
Activities
D-1 These
academic activities form a critical core of the educational program of the
department. It offers an opportunity of interaction between the junior staff
and the senior consultants. The juniors
get an opportunity to make presentations to the whole department. The senior
members of the department also get a feedback on the performance of these
juniors. All members of the departments are expected to attend all activities.
The following is the schedule of activities held on a regular basis in the
department:
·
Saturday: Chart review
meeting monthly
Clinical meeting
sponsered by one of
the nutrition/drug
companies
·
Monday: Journal
club, alternating with clinical meeting
·
Tuesday: Journal
club, alternating with clinical meeting
Mortality meeting once
every two months
on Mondays and
Tuesdays
Radiology meeting
monthly
D-2 These
academic activities have been registered at the
D-2.i Hand-over (endorsement) meetings: These are held
every morning at 7.30 and afternoon at 1.30 between the unit doctors and the
on-call team. This ensures continuity of
care and identifies patients who need extra attention.
D-2.ii Clinical
Meeting: This meeting which is held every Monday or Tuesday at
D-3.iii Journal club: This is held every Monday or Tuesday at
D-4.iv Trainee Forum: This is the trainees rotating through the department
and holds on Monday at
D-5.v Radiology Meeting: Once a month a collection of interesting radiographs of
inpatients are presented for discussion with a consultant radiologist in
attendance.
D-6.vi Mortality Meeting: This is scheduled every two months to discuss any
mortality in patients admitted to any of the general wards, pediatric casualty
and neonatal wards. The meeting affords an opportunity for reviewing the whole
management of the child, highlighting any shortcomings so that everyone learns
from the experience. These deaths are also presented at the Hospital mortality
meeting.
D-7.vii KIMS program: As part of the KIMS training program, special sessions
are scheduled from time to time, addressing different issues of interest to the
candidates. Quite often there are visiting professors and other consultants who
present didactic lectures, and general consultation, which all members of the
department are expected to attend.
IT IS EMPHASIZED THAT ACTIVE
PARTICIPATION OF THE MEDICAL STAFF IN THE ACADEMIC ACTIVITIES WILL BE GIVEN
EXTRA WEIGHT FOR PROMOTION PURPOSES IN THE DEPARTMENT AND WILL BE ACREDITED IN
THE CONTINUOS MEDICAL EDUACATION (CME) PROGRAM.
CLINICAL AUDIT
·
Number of re-admissions within 30 days.
·
Transfusions:
Number < 2 units.
Number > 7 units.
·
Number of non-specific diagnoses at discharge.
·
Number transferred to another acute care facility.
·
Number of LOS > 7 days.
·
Number of mortalities
·
Number febrile at discharge
or within 24 hours of discharge.
·
Number of complications.
·
Number of infections.
·
IV infiltrates (%).
·
Number of medication errors.
·
Number of incident reports.
·
Number of patient/parent complaints.
·
Number of physician complaints.
·
Number of discharge agianst medical advice (DAMA).
·
Reports of potential problems referred from other medical
staff committees or hospital review functions (%).
UTILIZATION AUDIT
I Blood:
IA Documentation
of Blood Transfusion:
Admission Note or Clinical
Sheet MUST document amount of transfusion and indication for transfusion. The Record MUST reflect why transfusion was
preferred to therapy (Medical or Surgical).
Progress Note MUST indicate follow up Hemoglobin or Hematocrit value and
clinical response.
IB Criteria
for Justification for Transfusion of Red Cells into Pediatric Patients:
Hypovolemia due to surgery,
trauma, gastro-intestinal hemorrhage or other blood loss documented by one of
the following:
a). In
newborns with respiratory distress:
1). Hematocrit
less than 40%
2). Hypovolemia
is present as judged by:
a.
Pallor
b.
Pulse rate more than 160 per min.
c.
Systolic blood pressure less than 50 mm/Hg (birth weight more than 1000
g)
3). Greater
than 50% of the blood volume (5 ml/kg) has been removed within 48 hours and the
hematocrit less than 50% or hemoglobin concentration is less than 15 g per dl.
b). Newborns
in the absence of respiratory distress:
1) The hematocrit is less than 30% in the first
week of life
2) The pulse rate is more than 160 per min.
3) The
respiratory rate is more than 60 per min.
c)
As replacement in Newborns:
Admission Notes MUST document
amount of transfusion and indication for transfusion. Progress Notes MUST indicate follow-up
hemoglobin and hematocrit value, as well as clinical response.
IC Criteria
for Justification for Transfusion of Fresh Frozen Plasma:
1). History
or clinical course suggestive of a coagulation due to deficiency of soluble coagulation
factors, and/or bleeding documented by one of the following:
a). Prothrombin time more than 15 sec.
b). Activated partial thromboplastin time more
than 40 sec.
c). Coagulation studies pending at the time of
infusion.
2). Immunodeficiency syndromes documented by
history and evidence of decreased serum immunoglobulin levels in chart.
3). Chart must
document clinical response of the patient following infusion and must document
follow-up laboratory on the abnormal parameter upon which the justification
based.
ID Criteria
for the Use of Cryoprecipitate:
1). Decreased
circulating Factor VIII level documented blood of the following:
a). History of decreased VIII concentration and,
b). Prolonged activated partial thromboplastin
time,
c). VIII assay pending or completed
d). Absence of a VIII inhibitor on screening
tests.
2). Von
Willebrands disease documented by a positive or suggestive history and the
following laboratory studies:
a). Prolonged template bleeding time;
b). Decreased plasma Factor VIII activity;
c). Decreased platelet aggregation to normal
doses of ristocetin.
d)
Factor VII antigen decreased.
3). Hypofibrinogenemia
documented by ALL of the following:
a). History or clinical course suggestive of
decreased fibrinogen
b). Bleeding either actively or in the immediate
past
c)
Laboratory evidence of fibrinogen concentration of less than 100 mg per
dl.
Clinical response MUST be
recorded and follow-up laboratory data on the parameters on which the
justification was based must be documented.
Presence or absence of adverse reaction must be recorded.
IE Criteria
for Whole Blood Transfusion:
1). Packed
cells not available.
2). Acute blood
loss more than 1/3 patient's volume.
IF Criteria
for Frozen Red Blood Cells ( Washed):
1). Febrile
non-hemolytic transfusion reaction despite receiving washed or filtered red
blood cells.
IG Criteria
for Platelet Transfusion In ITP (rarely used otherwise):
1). Emergency
surgeries, severe head or orbital truama
2). Stop bleeding:
a) Platelet count less than 80,000
IH Criteria
for Fresh Frozen Plazma:
1). Correction
of clotting factor deficiencies (multiple)
II Criteria
for Cryoprecipitate:
1). Fibrinogen
level less than 100-125 mg/dl.
2). Patient
with DIC syndrome:
a). Prothrombin time (PT more than 15 seconds -
not on (anti-coagulants).
b). P.T.T. more than 35 seconds (not on
anti-coagulants).
IJ Criteria
for Albumin Infusion:
1). Acute blood
loss with fall of patient volume by 15%
2)
Plasma Protein Fraction (PPF).
3). Plasma
substitutes.
IK Criteria
for Immunoglobulin:
1)
Hepatitis A.
Prophylaxis
2)
Hepatitis B.
Prophylaxis
3) IV form given to ITP patients not
responding to steroids
4) Kawazaki disease
5) Some cases of AIHA
IL Criteria
for
1). Prophylaxis
for RH negative mother with no detectable anti-D antibody.
2). RH negative
mother, RH positive newborn (not immunized)
II Laboratory:
IIA Administration:
II A-1 Has the responsibility (technical and administrative) been
defined and assigned?
II A-2 Have the policies for most common tests been
printed and circulated? Have such
policies been supported by educational programs, (lectures, circulars, active
participation in departmental meetings and teaching rounds)?
II A-3 The responsibility for the assessment of the
quality of sample collection, the distribution of work and the efficiency of
reporting and delivery of reports has been specified in the Lab. Policy.
II A-4 The person authorized to co-ordinate and act on laboratory
quality control has been defined.
II A-5 The person responsible for departmental
supplies needs to be appointed. This
person has responsibility to
reject expired reagents and to close down the service if the supplies are
defective.
IIB Utilization:
II B-1 Inappropriate
utilization (scientific and technical), under-utilization or hazardous
utilization of laboratory services.
Identification of tests and test profiles that are over used.
II B-2 Appropriateness
of laboratory tests versus diagnosis.
Did the test ordered fit the sequential order of tests? Do the biochemist, bacteriologist and the
pathologist participate in medical and surgical rounds?
II B-3 Justification
of excess phlebotomies on a patient.
II B-4 Assess the
efficiency of the laboratory services in emergency work and in high-risk areas.
II B-5 Total number of
repeat tests and analyses and the reason for this.
II B-6 Identification
of the rank of doctors authorized to request stat or repeat tests.
II B-7 Accuracy of
interpretation and consultation obtained following the reporting of critical
values. Appropriateness of action taken
when critical values occur.
II B-8 Rate of
haemolysed blood specimens.
II B-9 Rate of lost
samples or lost reports.
II B-10 Adequacy of
communications. Timeliness of collection
of specimens and deliver of results.
II B-11 Wrong test
results to ward, outpatient department or physician.
IIC EQUIPMENT:
II C-1 Number of
equipment breakdowns.
II C-2 Equipment
downtime.
II C-3 Reagents not
available or expired.
II C-4 Adequate maintenance.
II C-5 Adequate
calibration.
II C-6 Adequate space.
II C-7 Adequate
technical staff
III Antibiotics:
1)
Doctors must commit themselves to a provisional
diagnosis, prior to any antibiotic prescription, in which to state suspected
site of infection and possible causative organism.
2)
Culture specimens must be taken prior to any antibiotic
administration.
3)
Antibiotics in category I can be prescribed by any
doctor. This has to be approved by a
registrar within 12 hours.
4)
Antibiotics in category II or the combinations of
category I and II can be prescribed by a registrar.
5)
Antibiotics administered for more than 12 hours cannot be
changed before 5 days, except by the consultant or senior registrar.
6)
On emergency, antibiotics can be stopped by any doctor. The registrar is to be informed immediately.
7)
Antibiotics can be administered for maximum seven
days. If the consultant decides to
extend the antibiotic therapeutic period, he must write the required antibiotic
for specific time, and MUST NOT use the term: “Repeat”.
8)
Antibiotics administered
intravenously for more than 5 days should be approved by consultant or senior
registrar.
9)
Antibiotics from category III can only be prescribed by
the consultant.
10)
Uses of Vancomycin must be stopped, unless sensitivity
test indicates it is the only drug, or MRSA positive , MRSA is the causative
factor or prescribed by the consultant.
11)
The Microbiology Department must circulate the isolates
of microorganisms and their sensitivity to antibiotics on quarterly basis.
12)
The prophylaxis policy and details of their indications
should be decided by the Departmental Council and presented to the Antibiotic
Committee for approval. This has to be reviewed on annual basis.
13)
This policy has to be revised twice a year.
14)
The Antibiotic Policy of the Hospital should be deployed
throughout the Hospital. A copy of the
Hospital Antibiotic Policy should be sent to The Under-secretary, The Assistant
Under-secretary and Infection Control Administration.